Crack Use As a Public Health Problem in Canada

COMMENTARY
Crack Use As a Public Health
Problem in Canada
Call for an Evaluation of ‘Safer Crack Use Kits’
Emma Haydon, BSc1,2
Benedikt Fischer, PhD1,2
ABSTRACT
Oral crack use (smoking) is a relatively neglected public health problem in Canada, in
comparison to injection drug use (IDU). There are indications that crack use in Canada
may be increasing. Crack smoking involves particular risks and harms, including possible
infectious disease transmission, which underline the need for targeted interventions. One
pragmatic grassroots intervention that has only recently begun or been discussed in several
Canadian cities is the distribution of ‘safer crack use kits’, which provide hardware for
crack smoking devices along with harm reduction information. In addition to the direct
benefits of using them, the kits may also bring previously ‘hidden’ marginalized crack
smokers in contact with health and social services. There has been considerable
controversy with regards to the distribution of the crack kits, within criminal justice, public
health, and the general public; this resistance appears quite similar to that experienced
when needle exchange programs (NEPs) were first being established. Systematic
evaluation of the crack kits is urgently needed in order to produce definitive evidence of
their health and other benefits, and to allow for evidence-based program and policy
decisions in the interest of public health.
MeSH terms: Crack cocaine; Canada; public health; harm reduction; evidence-based
medicine
La traduction du résumé se trouve à la fin de l’article.
1. University of Toronto, Toronto, ON
2. Centre for Addiction and Mental Health, Toronto
Correspondence and reprint requests: Dr. Benedikt Fischer, 33 Russell Street, Room 2035, Toronto,
ON M5S 2S1, Tel: 416-535-8501, ext. 4502, Fax: 416-260-4156, E-mail: [email protected]
Acknowledgements: Ms. Haydon acknowledges funding support from the Ontario Women’s Health
Council; Dr. Fischer acknowledges funding support from the Canadian Institutes of Health Research
(CIHR).
MAY – JUNE 2005
ompared with the attention directed at injection drug use (IDU),
oral crack use (smoking) is a fairly
neglected public health problem in
Canada. Attention is needed in light of the
fact that crack use may be increasing, poses
specific health risks, and is in need of targeted interventions. Publicly funded initiatives – including needle exchange programs (NEPs) or safe injection facilities
(SIFs)1-4 – have been established to prevent
the transmission of disease in injection
drug users (IDUs). Programs parallel to
those provided for IDUs to address the
risk of infection in the population of crack
users are being discussed, yet only a few
select initiatives have been implemented.
Below, we will briefly outline the public
health problem of crack use, describe the
intervention of ‘safer crack use kits’, and
point to lessons for public health practice
and research.
C
Crack use in Canada
Systematic data on the prevalence of crack
use are limited in Canada; however, several
indicators suggest that crack use is prevalent and may be increasing among urban
drug user populations.5,6 A recent surveillance report of 794 injection drug users
(IDUs) in Toronto, Regina, Sudbury, and
Victoria (I-Track) indicated that 52.2% of
the total sample had also used crack in the
last 6 months; in Toronto specifically
(n=221), 78.7% of those surveyed had
smoked crack. 7 Recent data from a
Canadian cohort of illicit opioid users in
five cities (OPICAN study) indicated that
54.6% (371/679) of baseline participants
had smoked crack in the 30 days prior to
the survey.8
The public health problem of crack
use
A few studies have recently identified crack
smoking as a possible risk factor for HIV,9-11
HCV,12-15 and tuberculosis (TB)16,17 transmission in drug-user populations. It is
hypothesized that infectious disease may
be transmitted via the sharing of crack
paraphernalia (‘pipes’), through which
contaminated blood particles are transmitted from one host to the other. Many
crack smokers have burns or cuts on their
lips,18 often remaining as open sores and
taking long to heal. 19,20 Most utilize
makeshift crack pipes, typically assembled
from metal (e.g., pop cans) and/or glass
CANADIAN JOURNAL OF PUBLIC HEALTH 185
CRACK USE AND PUBLIC HEALTH
materials featuring sharp edges; these are
heated to high temperatures and may
break.19,21,22
The particular social settings and
dynamics of crack use among marginalized
street drug users create situational conditions in which the sharing of drugs and
equipment are prevalent and often reinforced.21-24 Possible disease transmission
risk for crack users has also been observed
in the context of the social ritual of ‘shotgunning’, where crack smoke vapours are
blown into the mouth of another.25,26 In
addition, many crack users engage in risky
and unprotected sex (work) practices,
adding further infectious disease transmission pathways.9,27,28 As for illicit drug use
in general,29,30 a close association between
poverty, marginalization and crack use has
been reported for North America, with the
effect of hindering access to adequate
health and social services.31-34
‘Safer crack use kits’
Frontline community service providers in
Canadian cities have long pointed to the
hidden public health problem of crack use,
and the need for effective interventions.
The distribution of ‘safer crack use kits’
has emerged as a unique intervention.
Toronto’s Safer Crack Use Coalition
(SCUC) – an ad-hoc alliance of community agencies and individuals formed in the
year 2000 – was the first formal distribution network for these kits in Canada
(Lorraine Barnaby (SCUC), personal communication, 2004). Other Canadian cities
have recently organized or are in the
process of starting distribution of harm
reduction supplies, including Edmonton
(Streetworks Needle Exchange), Guelph
(AIDS Committee of Guelph), Ottawa
(Ottawa Public Health), Winnipeg
(Winnipeg Regional Health Authority)
and Vancouver (Vancouver Area Network
of Drug Users). The declared main objective of these initiatives is to prevent potential infectious disease transmission that can
occur through the sharing of crack pipes
and the use of ‘dangerous’ smoking hardware. Through the provision of harm
reduction supplies, crack users can have
their own crack pipes (similar to NEPs
providing users with their own needles).
An indirect yet equally important further
benefit of crack kit distribution may be the
outreach to crack users and the opportuni186 REVUE CANADIENNE DE SANTÉ PUBLIQUE
ty to link them with support and treatment
resources.3
The typical contents of a ‘safer crack use
kit’ are as follows:
• Pyrex stem with mouth piece (‘straight
shooter’)
• Metal screens (brass)
• Chapstick/Vaseline (for lips only)
• Hand wipes
• Alcohol wipes
• Matches and chewing gum
• Condoms (lubricated and non-lubricated)
• Packets of lubricant
In addition, health tips for drug users
and information on harm reduction services is typically included. The cost of each
kit is approximately $2.00 (Lorraine
Barnaby (SCUC), personal communication, 2004).35 In Toronto, these costs are
supported by SCUC fund-raising activities
and private donations, with individual
agencies handing out the kits providing
staff time and ‘in-kind’ support, as the
City of Toronto until recently did not provide any funding support* (Lorraine
Barnaby (SCUC), personal communication, 2004). It is estimated that SCUC
currently hands out about 2000 kits per
month in Toronto; many more could be
handed out based on perceived demand,
and some agencies have had to limit distribution efforts due to shortage of supplies.36
In Winnipeg, the kits have been distributed since the fall of 2004 at an average
rate of approximately 17 kits per day, and
are funded by the Winnipeg Regional
Health Authority.35 The kit distribution in
Winnipeg was briefly suspended in
November due to concerns about the safety of the glass stem materials included, yet
quickly resumed when it was determined
that no safer materials were available.39
The politics of crack use
Resistance to the crack kit initiative has
been considerable and multi-fold. In
Toronto, there have been reports that both
distributors and recipients of crack kits
were targeted by law enforcement, who
confiscated kits and laid charges under the
Controlled Drugs and Substances Act
(CDSA).36 Conversely, a spokesperson for
the Vancouver Police Department (VPD)
*
In 2004, Toronto Public Health made one-time
funding support available towards select materials included in the ‘safer crack kits’ (excluding
stems)
stated that “possessing or manufacturing
an item that could be used for a crack pipe
is not illegal”.40 Clarification on the legal
status of crack pipe distribution and possession is thus needed.
There has also been substantial political
and public controversy about the ‘safer
crack use kit’ initiatives. The Toronto Sun
commented that “…even All Saints
Church [a social service drop-in program]
is in the drug business, handing out crack
kits…”. 41 Similar public outcry has
occurred in Winnipeg: a ‘former crack
cocaine addict’ interviewed by the
Winnipeg Sun35 said of the crack kit distribution: “They’re crazy, they’re stupid.”
Public health and addictions officials in
both Toronto and Vancouver 36,40 have
expressed doubts about the relevance of
crack pipes in the transmission of disease
and the ability of hardware distribution to
reduce such transmission, even though
these links have been suggested in the literature. Other public health figures in
Canada, however – e.g., a regional director
of Toronto Public Health and the CEO of
the Addiction Foundation of Manitoba –
have supported the initiatives and point to
the importance of protecting the health of
those not yet ready to stop using crack.35,36
The current controversy around and
resistance to the crack kit initiative are
reminiscent of the politics of NEPs in their
early – and crucial – years (the mid-1980s
to early 90s). Then, many politicians vigorously refused to support an idea that
seemed to ‘facilitate’ drug use, the media
portrayed it as a step towards ‘legalization’,
and the police opposed it since it undermined their principal ownership of drug
use as a crime problem. Despite emerging
evidence on their beneficial impact, NEPs
in Western countries were only hesitantly
introduced and funded – with the consequence that a considerable amount of subsequent morbidity and mortality occurred
that could have been avoided.37,38
Evaluating ‘safer crack use kits’
Clearly, a systematic scientific evaluation
of the impact of crack kit distribution on
health status and risks of users is direly
needed for informed program and policymaking. So far, resources for such a study
have not been made available by key
potential funders. Even with research
funding available, producing definitive eviVOLUME 96, NO. 3
CRACK USE AND PUBLIC HEALTH
dence of the role of crack kits in reducing
infectious disease transmission may prove
difficult, due to parallel risk factors,
including current or past IDU, sex work,
and others. However, these challenges
could be addressed with adequate research
methodology. At the same time, it must be
recognized that a crucial benefit of the distribution of crack kits other than direct
disease reduction may include crucial service contact with marginalized drug users
who would have remained ‘hidden’. 36
Therefore, it appears that the distribution
of crack kits may offer avenues to reach
substantive groups of crack users, and also
to educate them about the health risks to
which they are exposed.
CONCLUSIONS
Crack use is a neglected yet increasingly
relevant public health problem in the larger context of illicit drug use in Canada’s
urban populations. Its harms are fuelled
by a complex myriad of health and behavioural risks, amplified by the forces of
poverty, marginalization and criminalization, predominant within the crack user
population. Crack kit distribution programs are pragmatic, community-driven
initiatives to reduce harm among crack
users. These initiatives ought to be evaluated for their impact as soon as possible in
order to allow evidence-based program
decisions. At the same time, it is evident
that the issue of ‘safer crack use kits’ is
embedded in the politics of ‘harm reduction’, which has unduly stalled potentially
important public health interventions for
high-risk drug users before. These lessons
ought to be recalled and applied to the
crack use problem by policy-makers at all
levels.
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...continues
RÉSUMÉ
La consommation orale de crack (en le fumant) est un problème de santé publique qui reçoit peu
d’attention au Canada en comparaison des drogues injectables. Or, il semble que la consommation
de crack augmente au pays. Cette consommation a des risques et des effets particuliers, notamment
la transmission des infections, qui donnent à penser qu’il faudrait élaborer des interventions
ciblées. Une intervention pragmatique récemment amorcée ou envisagée dans certaines villes
canadiennes est la distribution de « trousses de consommation de crack à risques réduits »; ces
trousses contiennent des pipes à fumer du crack et des conseils pour réduire les méfaits de cette
drogue. En plus de leurs avantages directs, les trousses peuvent mettre les services sociaux et de
santé en contact avec des fumeurs de crack marginalisés dont on ne soupçonnait pas l’existence.
La distribution des trousses suscite toute une polémique dans les milieux de la justice pénale et de
la santé publique, ainsi que dans la population générale; la résistance est semblable à celle qui
s’était manifestée lors de la mise en place des programmes d’échange de seringues. Une évaluation
systématique des trousses de consommation de crack est essentielle et urgente pour établir la
preuve absolue de leurs avantages et pour prendre des décisions conformes aux intérêts de la santé
publique dans l’élaboration des politiques et des programmes.
CANADIAN JOURNAL OF PUBLIC HEALTH 187
CRACK USE AND PUBLIC HEALTH
33. Logan TK, Leukefeld C. Sexual and drug use
behaviors among female crack users: A multi-site
sample. Drug Alcohol Depend 2000;58:237-45.
34. Metsch L, McCoy H, McCoy C, Miles C, Edlin
B, Pereyra M. Use of health care services by
women who use crack cocaine. Women Health
1999;30:35-51.
35. Landry F. Crack kits condemned: Seen as fueling
addiction. Winnipeg Sun August 28, 2004.
Reprinted at http://canadianharmreduction.com
(Accessed October 1, 2004).
36. Polo J. Crack flak: Front line workers worry
about the spread of hepatitis C as city refuses to
fund safe crack kits. NOW Magazine
2003;23(13):24.
37. Lurie P, Drucker E. An opportunity lost: HIV
infections associated with lack of a national needle-exchange programme in the USA. Lancet
1997;349:604-8.
38. Fischer B, Rehm J, Blitz-Miller T. Injection drug
use and preventive measures: A comparison of
Canadian and Western European jurisdictions
over time. CMAJ 2000;162:1709-13.
39. Landry F. Put that in your pipe: WRHA resumes
handing out of crack kits. Winnipeg Sun
December 4, 2004. Reprinted at http://canadianharmreduction.com (Accessed January 25,
2005).
40. Carrigg D. Free crack pipes on the way.
Vancouver Courier September 19, 2004;8.
41. Levy S-A. Millions spent feeding addicts their
poison. Toronto Sun April 9, 2002;24.
Received: June 11, 2004
Revisions requested: September 24, 2004 & January
19, 2005
Revised mss: October 6, 2004 & January 28, 2005
Accepted: February 9, 2005
188 REVUE CANADIENNE DE SANTÉ PUBLIQUE
Éditorial, suite de page 166…
duits toxiques et la teneur affichée sur les
paquets de cigarettes au Canada. Ils ont
comparé la teneur des cigarettes « légères »
et « ordinaires » obtenue selon le protocole
de laboratoire prescrit par le gouvernement
de la Colombie-Britannique (norme ISO
modifiée) plutôt que par la méthode classique au Canada (norme ISO). Adoptant la
démarche en vigueur dans l’industrie alimentaire, ils ont cherché à évaluer si les
cigarettes « légères » affichent une teneur
en produits chimiques inférieure d’au
moins 25 % aux cigarettes « ordinaires ».
Or, leur analyse montre qu’il n’existe pas
de différence fondamentale entre les deux6.
Mais au lieu de faire valoir que ces
preuves supplémentaires militent en faveur
de la suppression des descripteurs des produits du tabac qui sèment la confusion
(comme « douces » et « légères »),
Gendreau et Vitaro semblent suggérer que
l’on soumette ces produits à une version
modifiée des pratiques canadiennes d’étiquetage des aliments. « Un compromis
possible, notent-ils en conclusion, serait
d’autoriser l’emploi de l’étiquette “légère”
uniquement lorsque la teneur d’une cigarette en un constituant donné est
inférieure d’au moins 25 % à celle des cigarettes “ordinaires” selon la norme ISO
modifiée6. » Une telle approche ne contribuerait, à mon avis, qu’à entretenir la
confusion décriée à juste titre par ces
mêmes chercheurs. Les fumeurs ajustent en
effet la façon dont ils fument de manière à
inhaler la dose idiosyncratique de nicotine
qu’ils préfèrent7. Quel que soit l’étiquetage
du produit, ils modifieront leur comportement et leur consommation de cigarettes
de manière à garantir un certain apport en
nicotine. Si l’on donne suite à la suggestion
de Gendreau et Vitaro, les fumeurs continueront sans doute de croire à tort que le
fait de fumer des cigarettes « légères », peu
importe la définition ou l’indicateur choisi,
procure des avantages pour la santé et
pourrait accélérer le processus de renonciation au tabac. Or, rien n’est plus faux8.
Comme l’indiquent eux-mêmes les
auteurs, « …le seul moyen de réduire son
exposition aux toxines de la fumée de cigarette est de réduire sa consommation de
cigarettes, et non de fumer des cigarettes
“légères”6. »
Depuis déjà un certain temps, les
autorités sanitaires canadiennes font allusion à une interdiction prochaine des
descripteurs « légères » et « douces » pour
les cigarettes. Malheureusement, les choses
en restent là. Ailleurs dans le monde, des
autorités agissent pour dissiper la confusion : le Parlement européen a adopté une
directive qui interdira l’étiquetage
trompeur9; la Convention-cadre de l’OMS
pour la lutte antitabac (déjà adoptée par
plus de 60 nations) exige des pays
adhérents qu’ils interdisent de tels descripteurs10. Le Canada, un signataire précoce, a
ratifié la Convention à la fin de 2004. Le
projet de loi C-71 (la Loi sur le tabac) confère au ministre canadien de la Santé le
pouvoir d’interdire les messages faux et
trompeurs sur les emballages des produits
du tabac11. Le ministre devrait utiliser ce
pouvoir, et il devrait le faire bientôt. L’étiquetage trompeur est malhonnête et, à la
limite, dangereux. Il doit cesser.
Voir les Références à la page 166.
VOLUME 96, NO. 3